Emotional Support Animals: From Skeptical Prescriber To True Believer

There is a new hot accessory to bring to your psychiatrist’s office...a pet. Just in the past month or so, I have seen what feels like a rampant increase in large dogs, small dogs, and cats outside our psychiatry building.

As a pet lover, I did not think much of this increase. As a psychiatrist, the increase generally made sense as I have written a few emotional support animal (ESA) notes during training. While writing the notes, I have mostly thought to myself something along the lines of: “A dog note? That is easy and harmless, much more so than prescribing or increasing doses of medications. Why would I NOT write the note?”.

Consider me one of the guilty ones. I prescribed ESAs to my depressed and anxious patients, without truly understanding the implications. I knew the definition of “emotional support” by the government was an untrained companion of any species that provides solace to someone with a disability, such as anxiety or depression. I knew these dogs were somehow different from “therapy” dogs and “service animals”, but did not really understand the intricacies of this difference. For example, ESAs are not covered by the Americans with Disability Act, while Service Animals are. They are also specific to the individual owner, and not used for all patients, like therapy dogs are.

http://angelpawstherapy.org/service-dogs.html

I had some inkling the note would then be used for travel or housing, but I did not know the details of the Fair Housing Act or Air Carrier Access Act. I also did not truly comprehend the extent of the abuse of the term “emotional support” — as in emotional support llamas, snakes, and turtles. This has lead to an increase in pets on airplane cabins each year to nearly 100,000 and, in California alone, a 10-fold increase in the number of “psychiatric” service dogs. Though I have never prescribed an emotional support pig and laugh slightly at the idea, in writing my notes, I unknowingly contributed to an epidemic of sorts. One perceived by many to actually just be a “scam.”

The truth is, I tended to agree. Despite my belief in its harmlessness, I also had a high degree of skepticism around the actual concept of an ESA. Though my patients all had legitimate psychiatric diagnoses, my gut reaction as a prescriber and travel consumer was “OK. Who actually medically NEEDS a pet?” And, on the flip side, “What pet ISN’T providing emotional support?”

As a skeptic, but a continued prescriber, I began to feel guilty about writing these notes so easily. Like any good intellectualizing type, I knew my guilt might go away with proof. So, as dogs seemed to be the most prescribed ESA, I asked the internet: Are dogs really therapeutic, and, why?

Most reviews (see Freidmann and Son and Marino) in the literature found that for a wide range of disorders (Alzheimers, schizophrenia, developmental disabilities), animal therapy has led to positive outcomes. The benefits were further confirmed in a 2012 study of psychiatric uses for animal-assisted therapy, which concluded that animals are especially helpful in improving social and communication skills, easing anxiety, lifting mood, and boosting empathy. In fact, Beck and Katcher showed that when a person interacted with, or was in the presence of, a friendly dog, their breathing became more regular, heart beat slowed, and muscles relaxed. This suggests dogs reduce stress. Even in a medical student cohort, a short playtime with a dog lead to major declines in anxiety and negative mood scores, and increases in positive mood scores. This was irrespective of previous dog experiences. Despite these studies, some believe the evidence is flawed methodologically and by no means definitive for the use of ESAs.

Perhaps the benefit is innate to dogs themselves. Dogs make us more comfortable, lowering barriers to communication. This was described by Sigmund Freud who had a Chow Chow named Jofi in his therapy sessions. Initially there for the psychoanalyst’s own calming, Freud soon noticed the benefit of having Jofi in psychotherapy: Patients were more willing to talk and more willing to talk about challenging and painful topics. This was particularly true of adolescents and children. His observations were later confirmed with data, including one in the substance abuse population.

Dogs also truly value human connection. Using brain imaging, dogs were found to prefer praise from their owners over food. Dogs also have maximal caudate activation to smells of the “familiar human” (without the owner present) and had positive associations with it. All of this suggests that instead of being purely driven by food, or what an owner can provide, dogs actually value human contact and connection. This may lead to the feeling of being “wanted” and bonded with one’s dog, or really the concept of “man’s best friend”.

Ultimately, despite my cynicism and nonchalant evaluation, my prescribing of a dog might actually have been evidence based medicine. The data, and even Sigmund Freud’s anecdotes suggest that dogs are therapeutic and “emotionally supportive”. This was only further cemented by my own personal experience.

On October 27, 2016, my dog of 8 years, Leo, died suddenly of an unknown cause after an intensive care stay. Amidst the support from friends, and the contradictory feelings of "he's just a dog”, I was (still am) heartbroken by his death. To be honest, I was shocked by how strong my reaction was. But, I’m not anymore.

The truth is mourning the loss of an emotional support makes sense. What are you supposed to feel when your emotional support dies?

Ultimately, while I don’t know about llamas, or snakes, I know about dogs. And, I will never doubt my prescription of one to a depressed or anxious patient again.

In Memory of Leo: 2008-2016

The opinions expressed herein are solely my own as a psychiatry trainee and mental health advocate. I receive no support from any pharmaceutical or device company.